xxxx CC Application Appendix d

Appendix D: Matrix of Current Counselors
(Application for Approval as a Nonprofit Budget Counseling Agency)

Name of Agency:
Other business names used at this location, if any:
Street address:

10.

9.

8.

7.

6.

5.

4.

3.

2.

1.

__________

Supervisor (check)
EDUCATION - Highest Degree Received (check one)
High School
A.D.
B.A./B.S.
M.S.
J.D.
Other *
COUNSELOR CERTIFICATION (check all that apply)
Accredited or Certified by
Independent Organization*
Course of Study*
CFP
AFC
CPA
EXPERIENCE (state years of experience)
Credit Counseling
Personal Financial
Management
Consumer Credit Education
Financial Planning
Marketing & Sales
Other
BACKGROUND (state the year of criminal check and check if no criminal conviction for felony, fraud, dishonesty, or false
statements)
Criminal Check
No Criminal Conviction
* Disclose on separate page. See Section 5 of Instructions for appropriate disclosures.

(Copy this page for
additional employees)

Counselor Names
Total number of
personnel at this
location: